Longitudinal study of symptom control and quality of life indicators with patients receiving community-based case management services.

A longitudinal study examined seven outcomes of chronically ill patients receiving community-based case management services. A repeated-measures analysis showed that these patients reported greater satisfaction with quality of life and personal well-being and controlled their symptoms better, but declined in self-care activities of daily living and in self-care instrumental activities of daily living.

The Extent to Which Performance-Based Financing Programs' Operations Manuals Reflect Rights-Based Principles: Implications for Family Planning Services.

Recognition is growing that development programs need to be guided by rights as well as to promote, protect, and fulfill them. Drawing from a content analysis of performance-based financing (PBF) implementation manuals, we quantify the extent to which these manuals use a rights perspective to frame family planning services. PBF is an adaptable service purchasing strategy that aims to improve equity and quality of health service provision. PBF can contribute toward achieving global family planning goals and has institutional support from multiple development partners including the Global Financing Facility in support of Every Woman Every Child. A review of 23 PBF implementation manuals finds that all documents are focused largely on the implementation of quality and accountability mechanisms, but few address issues of accessibility, availability, informed choice, acceptability, and/or nondiscrimination and equity. Notably, operational inclusion of agency, autonomy, empowerment, and/or voluntarism of health care clients is absent. Based on these findings, we argue that current PBF programs incorporate some mention of rights but are not systematically aligned with a rights-based approach. If PBF programs better reflected the importance of client-centered, rights-based programming, program performance could be improved and risk of infringing rights could be reduced. Given the mixed evidence for PBF benefits and the risk of perverse incentives in earlier PBF programs that were not aligned with rights-based approaches, we argue that greater attention to the rights principles of acceptability, accessibility, availability, and quality; accountability; agency and empowerment; equity and nondiscrimination; informed choice and decision making; participation; and privacy and confidentiality would improve health service delivery and health system performance for all stakeholders with clients at the center. Based on this review, we recommend making the rights-based approach explicit in PBF; progressively operationalizing rights, drawing from local experience; validating rights-based metrics to address measurement gaps; and recognizing the economic value of aligning PBF with rights principles. Such recommendations anchor an aspirational rights agenda with a practical PBF strategy on the need and opportunity for validated metrics.

Risk factors affecting nutritional status of dialysis patients: a quality improvement project.

People with chronic kidney disease on dialysis are at very high risk for protein energy malnutrition (PEM). It is well documented that malnourished patients have increased frequency of hospital admissions, longer hospital stays, lower quality of life, and increased risk of death. Serum albumin level is a valid measure for nutritional status of PEM. Clinical practice guidelines for nutrition, established by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI), recommend that patients on dialysis achieve an albumin of 3.7 g/dL (BCP) to ensure optimal nutrition and decrease risks of PEM. At Mercy Dialysis Center, it was determined that only 6% (n=97) of patients at Mercy Dialysis Center met this recommended albumin level. This led to an extensive continuous quality improvement project to improve these results. The nephrologist, nurse practitioner, dietitian, social worker, nurses, and dialysis technicians all contributed to this team project. PROJECT SUMMARY: Eleven risk factors for low serum albumin levels were identified. All patients at Mercy Dialysis Center were assessed for each risk factor. Interventions were implemented to reduce these risks. Serum albumin levels were tracked at the beginning of our study, at six months, and at one year on all patients. RESULTS: At the end of the study, 36% of the patients met the KDOQI recommendations for serum albumin levels (compared to only 6% prior to the project), and albumin levels overall improved. The risk factors that affected our patients the most included: dentition, infections or sepsis, multiple medications, and pain. It was determined that these, and all other risk factors had an impact on the nutritional status of our patients and need to be addressed on a regular basis.